Clinical Placement

Home , Churchill Hospital, John Radcliffe Hospital

Acute Adult Speech and Language Therapy

Clinical Placement

Student Information Pack 2020/2021

**PLEASE NOTE THAT FROM SEPTEMBER 2020 THERE MAY BE MODIFICATIONS TO CLINICAL PLACEMENTS DURING THE COVID-19 PANDEMIC IN LINE WITH OUH TRUST AND NATIONAL POLICY. INDIVIDUAL STUDENTS WILL BE CONTACTED BY THERE DESGINATED PLACEMENT EDUCATOR TO DISCUSS EACH PLACEMENT BEFORE THEIR START DATE**

CONTENTS

Departmental Information:

Pages 3-8: NEUROSCIENCES DEPARTMENT

Pages 9-10: ENT DEPARTMENT

Pages 11-12: THE BLENHEIM HEAD AND NECK UNIT, CHURCHILL HOSPITAL

Page 13: CHURCHILL HOSPITAL, OXFORD

Pages 14-15: HORTON HOSPITAL, BANBURY

Pages 14-17: JOHN RADCLIFFE HOSPITAL, OXFORD

Page 18: EARLY SUPPORTED DISCHARGE FOR STROKE

Pages 19-20: OXFORD CENTRE FOR ENABLEMENT (OCE)

Pages 21-22: AAC SERVICE

NEUROSCIENCES DEPARTMENT, L2 WEST WING, JOHN RADCLIFFE HOSPITAL

The S< Neurosciences Department is made up of a Highly Specialist Neurosciences Speech and Language Therapist and a Specialist Neurosciences Speech & Language Therapist forming 1.0wte.

Claire McMahon (Highly Specialist SLT-Neurosciences) works Monday and Tuesday. Daniela Carrasco (Specialist SLT Neurosciences) works Tuesday – Friday (9.30am – 2.30pm).

Our office is based in the Neurosciences Rehabilitation Department on Level 2 of the West Wing at the John Radcliffe Hospital and our direct line is 01865 231714. We can also be contacted via e-mail – [email protected] and [email protected]

This placement may not be suitable for students with mobility issues, students are likely to be mobile, spending much of the day standing at bedside and walking between patient bed spaces across three floors. Lifts are available. A car is not essential.

We offer an inpatient service to the Neurosciences ward and Neuro Intensive Care (NICU). The main ward is occupied by patients who have a range of neuro-medical and neurosurgical conditions (54 beds). We also have a high dependency unit (8 beds) providing a step down from NICU. Neuro Intensive Care is a separate 16 bedded ward. We also provide a service to the Neuro-Investigation ward, which is a 12 bedded day ward.

In addition, we also provide input to SSIP ward (specialist surgery inpatients). This includes patients who have had plastics or ENT surgery input.

1. Neuromedical beds Patients may have neurological conditions such as Parkinson ’s disease, MND, Myasthenia Gravis, Lambert-Eaton Syndrome, Guillain-Barre Syndrome, Miller Fisher Syndrome, Multiple Sclerosis, Multiple Systems Atrophy, Dermatomyositis, Encephalitis, CVA, and Lateral Medullary Syndrome.

2. Neurosurgical beds Patients may have conditions such as cerebral tumours, aneurysms, acoustic neuromas, head injuries, subarachnoid haemorrhage, and subdural haematoma. These patients may have had surgical procedures, such as debulking of a tumour, ventricular drainage, coiling or clipping of an aneurysm, embolisation, and craniotomy.

3. Neuro-Intensive Care Unit (NICU). Patients on this ward may present with any of the above conditions and are acutely unwell. Often they will be on assisted ventilation and may have a tracheostomy.

SUMMARY OF CONDITIONS / DISORDERS

The following summarises the neurology of the more common disorders that you may see whilst on placement. You may want to familiarise yourself with the speech, language and swallowing aspects of some of these disorders.

Neuromedical

Myasthenia Gravis is the most common primary disorder of neuromuscular transmission. The usual cause is an acquired immunological abnormality, but some cases result from genetic abnormalities in the Neuromuscular Junction (NMJ). In MG, the neurotransmitter Acetylcholine (the chemical that transmits impulses between nerves and muscles) is blocked by antibodies to its receptor. Patients present with limb weakness, ptosis or diplopia, aphonia, dysarthria and dysphagia. Symptoms become worse with prolonged muscle movement.

Lambert-Eaton Syndrome (myasthenic syndrome) is a disorder with symptoms very similar to those of Myasthenia Gravis. There is muscle weakness associated with disturbed communication between nerves and muscles. In Lambert-Eaton Syndrome, the distortion is caused by an insufficient release of neurotransmitter by the nerve cell. As muscle contraction continues, the amount of neurotransmitter may build up in sufficient quantities and result in increased strength. Therefore, clinically, MG results in weaker muscle movement with continued use, and LEMS in stronger muscle movement.

Multiple Sclerosis – The central nervous system becomes inflamed and destroyed by the patient’s own immune system in a process called demyelination, which usually starts in adult life. There are three different patterns: relapsing/remitting MS (80% show this pattern), secondary progressive MS (follows on from the relapsing/remitting type in 50% of cases within 10 years. Recovery from relapses is incomplete, and the relapsing pattern is progressively lost.) Primary progressive MS occurs in 10-15% of patients. Symptoms do not remit and progressively worsen with time from the onset of the condition. Symptoms include pain, fatigue, bowel and bladder problems, spasticity, depression (36%), anxiety (25%). We are asked to see MS patients with speech and swallowing problems, but have also encountered language disorders in this client group.

Gullian-Barre Syndrome is an acute inflammatory demyelinating disorder that affects the peripheral nerves, sympathetic and parasympathetic nerves. 50-70% of GBS patients have had a recent viral or bacterial infection. It is an auto-immune disease. That is, the body’s own immune system begins to attack the body itself. In GBS, motor weakness of more than one limb occurs progressively over days to six weeks. Recovery takes weeks to months. Miller Fisher Syndrome is a variant of GBS, and is characterised by abnormal muscle coordination (ataxia), opthalmoplegia (paralysis of eye muscles) and absence of reflexes.

Motor Neurone Disease is a progressive condition characterised by degeneration of motor neurones in the cortex and the anterior horns of the spinal cord, and degeneration of cranial nerve nuclei within the brainstem. Sensation is preserved in people with MND. Different terms are often used to describe involvement at each level of the CNS .

• Amyotrophic Lateral Sclerosis (ALS) accounts for 66% of cases, and is a mixture of both upper and lower motor neurone involvement. It is characterised by muscle weakness, spasticity, hyperactive reflexes and emotional liability. • Progressive Bulbar Palsy (PBP) (25% of cases) degenerates the nerves that control speech and swallowing.

• Progressive Muscular Atrophy (PMA) affects mainly the lower motor neurones, and is characterised by muscle wasting and weakness, loss of weight and muscle twitching. • Primary Lateral Sclerosis (PLS) affects primarily the upper motor neurones, resulting in stiffness and spastic paralysis of the limbs.

Parkinson’s Disease occurs when certain nerve cells in the part of the brain called the substantia nigra die or become impaired. Normally, these cells produce a vital chemical known as dopamine. Dopamine allows smooth function of the body’s muscles and movement. The loss of dopamine production in the brain causes the primary symptoms of the disease. These are tremor, slowness of movement (bradykinesia), rigidity, and difficulty with balance. They present with hypokinetic dysarthria and dysphagia.

Multiple Systems Atrophy refers to three slowly progressive related disorders that affect the central and autonomic nervous system. There is a life expectancy of 10 years or less, and it is usually diagnosed in people over 50. Olivopontocerebellar atrophy affects balance, coordination and speech. Striatonigrad degeneration is a parkinsonian form, characterised by slow movement and stiff muscles. MSA with orthostatic hypertension (formerly Shy-Drager syndrome)is a form with predominant autonomic system involvement. In all three forms of MSA, the patient can have orthostatic or postural hypotension (an excessive drop in blood pressure when the patient stands up, causing dizziness or momentary blackouts). Other symptoms include stiffness, rigidity, loss of balance/coordination, impaired speech, breathing and swallowing problems, blurred vision, impotence, constipation and urinary difficulties. Most patients develop dementia in the late stages of the disease. There is no specific treatment. (National Institute of Neurological Disorders and Stroke)

Dermatomyositis is thought to be an autoimmune disease, meaning that the body’s immune system, which normally fights infections and viruses, does not stop fighting once the infection has gone. It is more common in women, and can occur at any age. It presents as a rash which looks patchy, reddish or purple. Some people also have hardened bumps under the skin. Muscle weakness usually happens over a period of days, and begins with muscles that are closest to and within the trunk of the body, e.g. neck, hip, shoulders. Some DM patients have dysphagia. Patients are treated with Prednisone, which is a steroid, to stop the body from attacking the muscles by slowing down the immune system. (The Myositis Association website)

Acoustic Neuromas are benign tumours of the 8th cranial nerve. Symptoms include hearing loss, tinnitus and imbalance. Treatment is either microsurgery aimed at complete removal of the tumour, or Gamma knife surgery, a radiosurgery technique to shrink the tumour over time. Microsurgery may result in hearing loss on the affected side, and 1 in 5 patients may suffer facial nerve damage, resulting in facial palsy. Whereas over 90% of patients who have Gamma knife surgery have no hearing loss or facial weakness. (British Association Acoustic Neuroma – BANA)

Encephalitis means inflammation of the brain. It can occur at any age, and is usually the result of a viral infection. There are two types of encephalitis – one is Acute Viral Encephalitis caused by a direct viral attack on the brain, and the other is Post Infectious Encephalitis, an autoimmune condition whereby the body’s immune system attacks the brain following an infection somewhere else in the body. Range of symptoms vary widely and include confusion, drowsiness, fits, coma, aversion to bright lights, inability to speak, personality changes, hallucinations and disorientation.

Lateral Medullary Syndrome (Wallenberg Syndrome) is a neurological disorder characterised by swallowing difficulties and hoarseness, which results from paralysis of a portion of the vocal folds. The paralysis is caused by a blockage in a cerebral or cerebellar artery.

(NINDS Wallenberg information page)

Progressive Supranuclear Palsy (PSP) is a disease of the brain which usually occurs in patients in their 60s, but can start as young as 40s. Survival rate is usually 6-10 years after first symptoms. In PSP, gradual loss of brain cells causes slowing of movement and reduced control of walking, balance, swallowing, speaking, and eye movement, especially downward direction. Other symptoms that occur in some are emotional and personality changes, such as increased irritability, angry outbursts, emotional lability, sleep disturbances, forgetfulness, mental slowing, apathy and difficulty with abstract reasoning. It is often mistaken for Parkinson’s disease because of the slowness, and Alzheimer’s because of the changes in mood and personality. The cause of PSP is unknown, but it is at least partly genetic. A brain protein caused tau accumulates in abnormal clumps in certain brain cells, causing the cells to die. There is currently no cure for PSP, although levodopa may give temporary benefit. (The Society for PSP website)

Huntington’s Disease is a hereditary disease which is caused by a faulty gene on chromosome 4. It is not yet fully understood how the faulty gene damages the nerve cells in the areas of the brain, including the basal ganglia and the cerebral cortex. Since so much of the brain’s activity passes through these areas, the death of these cells affects virtually everything about a person, including movement, moods and thinking processes. Symptoms usually begin between the ages of 30-50 years, and an individual may have the disease for 15-20 years.

Neurosurgical

Intracranial Aneurysms are dilated blood vessels within the skull. Usually, the cause is unknown, but people with genetic causes of weak blood vessels are more likely to develop aneurysms. Rupture of intracranial aneurysms causes subarachnoid haemorrhage and has a poor prognosis. About 30% of people die within 24 hours, and a further 25-30% die within four weeks. Treatment for aneurysms involves either clipping the abnormal blood vessel, or coiling (coil embolisation means the process by which a vessel is occluded with a material mass). The coil technique involves approaching the aneurysm from inside the diseased blood vessel, avoiding the need to open the skull. A thin tube containing the coil on a guidewire is inserted into a large artery, usually in the groin, and passed up to the skull under radiological guidance. The coil is placed inside the aneurysm and detached from the guidewire. Multiple coils may be placed into the aneurysm until it is densely packed. (NICE guidelines)

Craniotomy is the surgical removal of a section of bone (bone flap) from the skull for the purposes of operating on the brain. The bone flap is usually replaced at the end of the procedure. It is not replaced, the procedure is known as a craniectomy. A craniotomy is used for many different procedures within the head, e.g. trauma, tumour, infection, aneurysm. (YourSurgery.com)

External Ventricular Drainage (EVD): the brain and spinal cord are surrounded by cerebral spinal fluid (CSF) which helps protect them from damage. The area of the brain that contains this fluid are the ventricles. Sometimes, the CSF needs to be drained away from the ventricles, e.g. if there is a temporary blockage in the flow of CSF this will cause a build-up of CSF and a drain may be needed to reduce the pressure inside the brain. The EVD system uses a catheter placed in the ventricle of the brain and connected to a drainage system. (Institute of Child Health)

Ventriculoperitoneal Shunt: This is a device which drains the extra fluid in the brain into the peritoneal cavity where the fluid can be absorbed.

Stereotactic surgeries are commonly used to treat Parkinson’s Disease. The most important are deep brain stimulation (DBS), pallidotomy and thalamotomy. Stereotactic just refers to the special frame that is attached to the head during surgery. DBS involves the permanent placement of electrodes into the thalamus, the pallidum, or the subthalmic nucleus. These are the parts of the brain that are involved in movement in PD. The electrode is connected to a small battery-powered stimulator which is implanted under the skin just below the collarbone, and there is a wire which runs under the skin to the electrode. The stimulator provides electrical impulses that affect the nerve cells and improve some of the symptoms. Thalamotomy and pallidotomy are performed when rigidity, hypokinesia and tremor are present, but DBS is not appropriate. For thalamotomy, a thin electrode is placed into the thalamus, and a high frequency electrical current is applied to the electrode destroying a small part of the tissue around it. This produces an immediate benefit in reduction of tremor (thalamotomy), rigidity and hypokinesia (pallidotomy). During thalamotomy, there is a small risk of permanent damage to the voice, and for both procedures a higher risk of stroke than with DBS. (University of Virginia Health Systems website)

Caseload The caseload is solely for inpatients. The split between dysphagia and communication for inpatients in Neurosciences/Trauma is hugely variable but generally about 90% of patients are referred for dysphagia. Some of these patients will present with tracheostomies and some will also be ventilated. A good proportion of our patients may also have communication needs identified, e.g. dysarthria and dysphasia. On your placement you have the opportunity to see range of swallowing and communication impairments.

Opportunities for students in Neurosciences

1. You will have the opportunity to see acute inpatients. 2. You will take case histories and build up patient profiles. 3. You will have the opportunity to observe and participate in dysphagia assessments, treatment and reviews at the patient bedside. 4. You are likely to observe or carry out initial assessments for communication impaired clients and formulate profiles and plans. 5. You may have the opportunity to carry out some formal assessments 6. You will have the opportunity to observe and work jointly with the MDT to facilitate tracheostomy weaning. 7. You will be able to liaise with other members of the MDT including Doctors, Nurses, Dieticians, Physiotherapists, and Occupational Therapists. 8. You will gain experience at documenting patient records electronically.